Thursday, January 03, 2013

Africa Needs More Than Western AIDS Grants. Africa Needs Surgeons.

...The need for surgeons in sub-Saharan Africa is so profound that it's genuinely difficult to comprehend. "I was born by C-section, and when I was two months old I had an emergency operation on my stomach. When I was 23, I had appendicitis," Adam Kushner, a lecturer at Columbia Medical School, told me. "Those are three relatively simple procedures. A lot of people that have problems like those in say, Sierra Leone, just die," he said. "I mean, can you imagine a kid falling out of a tree, and then being disabled for the rest of their life because they couldn't get their arm fracture fixed? It's insane." Kushner's organization, Surgeons OverSeas, estimates 56 million people are in need of surgical care on the continent -- twice the population suffering from HIV/AIDS.

In 2009, Kushner worked with the Ministry of Health in Sierra Leone on an audit of the country's surgical capacity. Sierra Leone has a population of six million, roughly the size of Los Angeles and Houston combined, and the study found nine surgeons practicing in the country. The World Health Organization (WHO) estimates that a health system needs one surgeon for every 20,000 citizens to meet the burden of disease. By that measure, Sierra Leone has a shortage of 291 surgeons.

The deficit is equally dire elsewhere in Africa. Kenya and Uganda, with two of the continent's strongest medical education systems, have 355 and 100 surgeons respectively, meeting 19 percent and 7.4 percent of need based on WHO projections. Rwanda has 35. "Everyday I see things that just make me rage inside," Jim Brown, a missionary surgeon in Cameroon, told me.

The results of these deficits are often horrific, as surgical procedures that should be safe and routine -- appendectomies, caesarian sections, and amputations, for instance -- are carried out by general practitioners with little or no training, rather than surgeons. "Every week, almost every day, we have someone in here draining stool from an abdominal incision, or a ureter tied off, or the wrong operation done somewhere else," Brown said, standing atop a ward with 70 beds stretching in three directions. "And very often they die." Brown is slight, with an insufferably honest face and a subtle trace of southern to his locution.

"The ones that really get me are the ones that are told they had surgery -- they get anesthesia and incisions and they take their money, but they don't actually operate. They usually come up here after their third or fourth attempt somewhere else, and they've never had a fistulectomy, or a myomectomy, or whatever it is they need." At another hospital where Brown worked, prior to moving to Mbingo, he found that O.R. staff members were performing surgeries themselves after hours and on weekends.

"One of the biggest problems I see," Kushner told me, "is that ministries of health are hesitant to pursue surgical programs because the donors don't want it. The money is coming in and earmarked for certain programs. And even though you see a need for another type of program, you don't want to piss off your donors. There's this perception that surgery is expensive."...

Of the foreign aid dollars spent by the State Department on global
health last year, nearly half went to the purchase of antiretroviral
drugs for those
suffering from HIV/AIDS. The State Department and PEPFAR (the
President's Emergency Plan For AIDS Relief) provide financial assistance
for training through
a dizzying array of channels. The U.S. Agency for International
Development (USAID), the primary vehicle for State's foreign assistance
programs, couldn't
produce a figure for total dollars spent training foreign healthcare
professionals in recent years for me, let alone a figure for surgical
programs. In the
last two years, the Office of the Global AIDS Coordinator (OGAC) has
also rolled out $130 million in training related grants intended to
reach beyond
HIV/AIDS treatment toward bolstering health systems. The grants --
most of which range between $500,000 and $1 million over five years --
pair U.S. medical
schools with African counterparts and tackle a broad range of
issues. Surgery is notably scant in grant descriptions, and where it
does appear, it seems
like an addendum...

"The whole idea of valuing the patient is crucial to the training," Brown told me. "Without that change of heart, the temptations are just too great, for power, for prestige, for money. It's everything they've seen modeled. They're well trained now, and they can go push people around, so it energizes me when I see that, with nobody looking, they do the right thing."…

In 2008, two of the preeminent figures in international health policy published a paper on surgical need in the developing world. Paul Farmer, who teaches at Harvard Medical School, and Jim Kim, who now runs the World Bank, wrote: "Although disease treatable by surgery remains a ranking killer of the world's poor, major financers of public health have shown that they do not regard surgical disease as a priority." In Africa, they wrote, "surgery can be thought of as the neglected stepchild of global public health."

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